Recommended Approach for Headache Workup
The recommended approach for headache workup should focus on distinguishing between primary and secondary headache disorders through systematic evaluation of red flags, followed by appropriate diagnostic testing only when indicated by concerning features. 1
Initial Assessment
History Taking - Key Elements
- Duration and pattern: 4-72 hours for migraine, shorter for cluster headaches 1
- Pain characteristics: Location, quality, intensity, aggravating/relieving factors
- Associated symptoms: Nausea, vomiting, photophobia, phonophobia, aura 1
- Red flags (SNNOOP10): 1, 2
- Sudden onset ("worst headache of life")
- New headache pattern after age 50
- Neurological deficits
- Onset during exertion/Valsalva
- Occipital location
- Progressive worsening pattern
- Papilledema
- Precipitated by position change
- Pregnancy or puerperium
- Painful eye with autonomic features
- Pathology of immune system
- Painkiller overuse or new drug
Physical Examination
- Complete neurological examination
- Vital signs (fever may indicate infection)
- Fundoscopic examination for papilledema
- Meningeal signs (neck stiffness)
- Temporal artery palpation (for temporal arteritis)
- Sinus tenderness
- Ocular examination (for acute angle-closure glaucoma) 1
Diagnostic Algorithm
Step 1: Determine if Emergency Evaluation is Needed
If any of these are present, proceed to emergency evaluation:
- Thunderclap headache (sudden, severe)
- Fever with meningeal signs
- Focal neurological deficits
- Altered mental status
- Papilledema
- Signs of increased intracranial pressure 1, 2, 3
Step 2: Emergency Evaluation (if indicated)
- Non-contrast CT head (first-line for suspected intracranial hemorrhage) 1
- Lumbar puncture if CT normal but subarachnoid hemorrhage still suspected 2, 4
- CT venography if cerebral venous thrombosis suspected 1
Step 3: Non-Emergency Evaluation (if no red flags)
- Apply ICHD-3 diagnostic criteria for primary headache disorders 1
- For migraine: ≥5 attacks (without aura) or ≥2 attacks (with aura), duration 4-72 hours, ≥2 pain characteristics, ≥1 associated symptom 1
- For tension-type: bilateral, non-pulsating, mild-moderate intensity, not aggravated by activity 1
Step 4: Additional Testing (if indicated by history/exam)
- MRI brain with contrast: Preferred for non-emergent cases with concerning features 1, 4
- Specialized MRI protocols: Based on suspected etiology (e.g., MRI orbits for optic neuritis) 1
- Laboratory testing: CBC, ESR/CRP (for suspected temporal arteritis), basic metabolic panel 3
Management Considerations
Primary Headache Treatment
- Migraine: NSAIDs first-line (ibuprofen, ASA), triptans second-line 1, 5
- Preventive treatment: Consider for ≥4 attacks/month (beta-blockers, antiepileptics, anti-CGRP antibodies) 1
- Medication overuse: Monitor for overuse (≥15 days/month for NSAIDs, ≥10 days/month for triptans) 1
Special Populations
- Pregnancy: Acetaminophen safest for acute treatment 1
- Children: Ibuprofen for acute treatment; different management approach 1
- Older adults: Higher risk of secondary headache; limited evidence for medications 1
Common Pitfalls and Caveats
- Avoid unnecessary neuroimaging in patients with typical features of primary headache and normal neurological examination 2, 4
- Don't miss secondary headaches by failing to evaluate red flags thoroughly 3
- Beware of medication overuse headache in patients with frequent use of acute medications 1
- Consider cardiovascular risk when prescribing triptans (contraindicated in coronary artery disease, uncontrolled hypertension, history of stroke) 1, 5
- Monitor for serotonin syndrome when triptans are combined with SSRIs/SNRIs 1
Remember that while most headaches evaluated in primary care are benign, systematic evaluation for red flags is essential to identify potentially life-threatening secondary causes requiring urgent intervention 2, 3.